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Microsurgery refers to a surgi-cal procedure performed

under a microscope. It is a practicethat embraces three distinct values.First is enhancement of motor skillsto improve surgical ability. This isevident in the smooth hand move-ments accomplished with increasedprecision and reduced tremor. Sec-ond is the decreased tissue traumaat the surgical site, which is appar-ent in the use of small instrumentsand a reduced surgical field. Thirdis the application of microsurgicalprinciples to achieve passive andprimary wound closure. The aim isthe elimination of gaps and deadspaces at the wound edge to cir-cumvent new tissue formationneeded to fill surgical voids. Apainful and inflammatory phase ofwound healing can then be avoided.

The history of microsurgery datesfrom 1922 when Nylen first per-formed eye surgery under a microscope.1,2 By the 1960s micro-surgery was standard in many spe-cialties such as neurology andophthalmology.3,4 A factor in itsacceptance was lessened morbidityassociated with smaller wounds.Microsurgery has been practiced inendodontics since 1986.5 It wasintroduced to the specialty of periodontics in 1992.6

MAGNIFICATION IN DENTISTRY

Loupes have long been used in dentistry, but it is only in the pastdecade that microscopes have beenapplied to clinical dentistry. It isnow recognized that magnificationhas more to offer than correctivevision. Ergonomic benefits and

improved clinical skills are welldocumented.7–9 Why is the microscope not used routinely indentistry? Those who use no mag-nification believe that normalvision is adequate to deal with clinical work. This is born of theingrained certainty that the eye sees the world as it is. It is a per-ceptual bias deeply imprinted sincechildhood. Any challenge to visualreality is a fundamental challengeto the world as it is experiencedand is not readily believable. Clini-cians understand magnification,having been exposed to binocularsand cameras. However, the notionthat improved hand skills derivefrom magnification has not yetbeen appreciated.

*Director, Microsurgery Training Institute, Santa Barbara, CA, USA

Periodontal Microsurgery

DENNIS A. SHANELEC, DDS*

ABSTRACT

The purpose of this article is to introduce the history of microsurgery in the surgical disciplines.It reviews the benefits and potential applications of magnification and microsurgery in the spe-cialty of periodontics. Esthetic procedures encompassing periodontal plastic microsurgery aredescribed with an emphasis on clinical cases to demonstrate their application.

CLINICAL SIGNIFICANCE

The use of magnification, in particular the use of surgical operating microscopes, has increased inmany areas of dentistry. This article demonstrates the usefulness of microscope-enhanced peri-odontal surgery and addresses many issues involved in its application to the surgical discipline ofperiodontics.

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ADVANTAGES OF THE

MICROSCOPE IN PERIODONTICS

The surgical microscope allowshigh-level motor skills and accuracyin clinical care. This has been mea-sured in many surgical disciplinesbut cannot be fully appreciated untila surgeon tries his or her handunder the microscope. At ×40 mag-nification, vascular microsurgeonsroutinely anastomose vessels with adiameter of < 1 mm.10,11 At ×120magnification, biologists performsubcellular operations on mitochon-dria and chromosomes. Periodontalmicrosurgery is commonly per-formed at ×10 to 20 magnification.With normal vision the highest pos-sible visual resolution is 0.2 mm.12

At this level of visual acuity, thegreatest accuracy possible for thehuman hand movement is 1 mm.13

Physiologic tremor can furtherreduce the accuracy of movementto 2 mm.14 Under magnification of×20, the accuracy of hand movementapproaches 10 µ and visual resolu-tion approaches 1 µ (Figure 1).15

Proprioceptive guidance is of littlevalue under the microscope.16

Instead, visual guidance is used toaccomplish mid-course correctionof the hand to accomplish the finestmovement with skill and dexter-ity.17,18 This means incisions areaccurately mapped, flaps are ele-vated with minimal damage, andthe wound is closed precisely andwithout tension. For the patient thismeans that postoperative morbiditycan potentially be substantiallyreduced (Figures 2–8).

Figure 1. Microsurgical implant expo-sure with 557 bur.

Figure 2. Case 1. Miller Class I maxil-lary cuspid recession.

Figure 3. Case 1. Intrasulcular microin-cision using ophthalmic scalpel.

Figure 4. Case 1. Connective tissue graftpositioned with the first stay suture.

Figure 5. Case 1. Connective tissue graftpositioned with the second stay suture.

Figure 6. Case 1. Both stay sutures tied.

Figure 7. Case 1. Auxiliary microsuturesto prevent micromovement of the graft.

Figure 8. Case 1. Postoperative healingat 2 weeks.

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MICROSURGERY IN PERIODONTICS

The reason microsurgery has gainedacceptance among some periodon-tists is not reduced morbidity.Rather, the end-point appearance ofmicrosurgery is simply superior tothat of conventional surgery. Thedifference is shown in cleaner inci-sions, closer wound apposition,reduced hemorrhage, and reducedtrauma at the surgical site. The dif-ference is self-evident and can bestartling when compared with con-ventional surgery (Figures 9–11). Asmuch as judgment and knowledgeplay a role in surgery, in the end it isa craft. Surgeons appreciate crafts-

manship, especially when it rises toartistic levels greater than those pos-sible with conventional surgery.With a little training, an averageperiodontist can consistently pro-duce more finely crafted work thancan the most gifted conventionalsurgeon. The clinician’s personalgratification in performing moreideal work may be an importantfactor in the acceptance of micro-surgery in periodontics (Figure 12).

Periodontal surgery viewed underthe microscope reveals the coarse-ness of most surgical manipula-tion.19,20 What appears as gentle

handling of tissues is discovered tobe a gross crushing and tearing (Fig-ure 13). The microscope is a toolthat permits less traumatic and lessinvasive surgery. Using of 7-0 to 9-0microsutures allows more precisewound closure (Figures 14–16).This encourages repair through pri-mary healing, which is rapid andrequires less formation of granula-tion or scar tissue. Wound healingstudies show anastomosis of micro-surgical wounds within 48hours.6,21,22 Secondary wound heal-ing is slower because new tissueformation is required to fill voids atthe edge of the partially closed

Figure 9. Case 2. Miller Class I maxil-lary cuspid recession.

Figure 10. Case 2. Microsuturing.

Figure 12. Example of the geometry ofmicrosuturing.

Figure 13. Example of conventionalsurgery suturing later viewed under amicroscope.

Figure 11. Case 2. Postoperative heal-ing at 2 weeks.

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wound. Because surgical trauma isminimized during microsurgery, lesscell damage and necrosis occurs.This means less inflammation andreduced pain (Figures 17–19).

Periodontal microsurgery does notcompete with conventional peri-odontal surgery. It is an evolutionof surgical techniques to permitreduced trauma. Its methodologyimproves existing surgical practiceand introduces the possibility forbetter patient care to periodontics.

Periodontal Plastic SurgeryPlastic surgery is a clinical disci-pline in which surgical techniquesare employed to reconstruct orrepair bodily structures. These maybe missing, defective, or damagedthrough injury or disease. Plasticsurgery relies on mobilization ofsoft tissue flaps for advancement orretraction in combination with theaddition or removal of tissuebeneath the flap. Such techniquesare capable of molding tissues torestore a lost part or improve func-

tion and esthetic appearance. Theapplication of plastic surgical prin-ciples to periodontal tissues com-prises the field of periodontalplastic surgery. Periodontal plasticsurgery, with its emphasis on esthet-ics, is an important aspect of peri-odontal practice.23,24

Types of Periodontal Plastic Micro-surgery. There are two basic perio-dontal procedures in whichperiodontal plastic microsurgerymay be applied: those relative to

Figure 14. Case 3. Preoperative MillerClass I maxillary cuspid recession.

Figure 15. Case 3. Microsurgical closure. Figure 16. Case 3. Postoperative heal-ing at 2 weeks.

Figure 17. Case 4. Miller Class Imandibular cuspid recession.

Figure 18. Case 4. Microsurgery withintrasulcular incisions.

Figure 19. Case 4. Postoperative viewat 1 week with microsutures in place.

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the level of the dentogingival junc-tion and those relative to the eden-tulous ridge. With regard to thedentogingival junction, micro-surgery can be employed to addgingival tissue where it is absent orto remove gingival tissue where it is excessive. Periodontal plasticmicrosurgery of the edentulousridge most often involves the addi-tion of bone and or soft tissue.

Correcting Gingival Recession.Periodontal plastic microsurgicalreconstruction of gingival tissueover denuded roots can be routineand predictable using subepithelialconnective tissue grafting. The colormatch and esthetic appearance ofsuch grafts is greatly improved overthe original free gingival graft tech-nique. When carefully closed, palataldonor sites can heal by primaryintention without a painful period ofopen granulation. This greatlyreduces postoperative morbidity.

Establishing an Esthetic Smile Line.An abnormal smile line may resultfrom a number of causes, includinggingival recession, abnormal erup-tive patterns, incisal wear, andexcessive tissue growth of variousetiologies. The creation of an idealesthetic smile with harmonious gin-gival contours involves many fac-tors. Foremost among these aresymmetry, lip position, and relativegingival levels of adjacent teeth.Complex periodontal plastic micro-surgery involving removal of tissueon some teeth and replacement onothers may be required.

Restoring the Edentulous Ridge.Ridge augmentation can involve avariety of techniques, includingguided bone regeneration, block andparticulate grafts, soft tissue grafts,and a combination of these. In addi-tion to establishing adequate verticalheight, sufficient soft tissue thick-ness must be created to provide an

emergence profile for pontics or adental implant prosthesis. Papillareconstruction may be viewed con-ceptually as a microsurgical variationof ridge augmentation periodontalplastic microsurgery between twoadjacent teeth (Figures 20–22).25,26

CONCLUSIONS

Periodontal microsurgery is in itsinfancy but will play a role in thefuture.27,28 It is a skill that requirespractice to achieve proficiency. Thesmall scale of microsurgery presentsspecial challenges in dexterity andperception. Its execution is tech-nique sensitive and more demandingthan are conventional periodontalprocedures. As the benefits of themicroscope are realized, it will beapplied more universally.

There are many indications in whichperiodontal microsurgery can bebeneficial. It appears to be a naturalevolution for the specialty of peri-

Figure 20. Case 5. Papilla loss owingto periodontal surgical misadventure.

Figure 21. Case 5. Papilla reconstruc-tion via a microsurgical procedure.

Figure 22. Case 5. Papilla reconstruc-tion at 4 weeks postoperatively.

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odontics. Microsurgery offers newpossibilities to improve periodontalcare in a variety of ways. Its benefitsinclude improved cosmetics, rapidhealing, minimal discomfort, andenhanced patient acceptance.

DISCLOSURE

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Reprint requests: Dennis A. Shanelec, DDS,Director, Microsurgery Training Institute,1515 State Street, Suite 1, Santa Barbara,CA, USA 93101; e-mail mti@microden-tistry.com©2003 BC Decker Inc